complaint·April 24, 2024

9099C-1... Allegation: Staff are not properly trained. The complaint alleges staff are not trained and that training documentation is false. LPA requested all staff files be made available for review since they were not accessible when LPA was at the facility on 3/27/24. The Administrator stated the files were in electronic/PDF format on her laptop which was at another location during the inspection on 3/27/24. The administrator emailed LPA (3) staff files for staff (S1, S2 and S3) on 4/8/24. All (3) staff had current First Aid/CPR certifications on file, but there was no documentation that staff (S1) or (S3) had completed the required initial and/or continuing training related to ADL's or medication administration. LPA observed documentation that (S2) had completed hospice care and Dementia care training in April 2024. LPA requested to review the remaining staff files on 4/24/24, but the files were not able to be accessed due to the Administrator being the only one who has access; however, LPA confirmed that (S4) completed First Aid/CPR certification prior to beginning to work at the facility. Based on the the training documentation that was viewed, the part of the allegation about documentation being "false" is not able to be substantiated. Based on (3) staff files that were able to be reviewed and the remaining staff files that were not able to be reviewed to confirm that all staff have completed all required training, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff files are incomplete. The complaint alleges staff health screenings are not completed and the criminal record statements are not signed. LPA reviewed health screenings and criminal record clearances for (6) staff files. (5) of (6) criminal record clearances were signed. LPA observed staff (S6) sign the LIC508 during the inspection on 4/17/24. Health screenings for (3) staff (S2, S5 and S6) appeared that some parts were photocopied and used more than once. Based on documentation reviewed, LPA finds the allegation to be SUBSTANTIATED- meaning the allegation is valid because the preponderance of the evidence standard has been met. Exit interview. Copy of report and appeal rights provided to the House Lead. 9099A-C-1... The incident report notes resident fell from her bed and sustained the fall; however, the Administrator stated staff, (S7) initially told her (R1) fell from her bed but then later said she was "not sure." Staff, (S2), stated she was present on 3/9/24 when resident fell and stated she was told by (S7) that (R1) fell from the chair in her room and not from the bed. Resident's family member stated she was also told by a staff member that resident fell from the chair. (S2) stated she was the one who immediately called the Administrator to report the fall and resident was sent out to the emergency room promptly. The Administrator stated the resident was sent to the Emergency Room once she was made aware of the fall by the caregiver, an hour later. The report notes resident returned from the hospital (4) hours later to the facility. (R1) was placed on hospice care on 3/15/24 due to a terminal diagnosis of cerebral atherosclerosis. Hospice notes also document that resident had “extensive bruise to face” and “head bump to left forehead”. Resident’s current physician’s report (Dec 2023) notes resident has a primary diagnosis of Syncope and Collapse and congestive heart failure and is noted as being non-ambulatory based on physical condition. Resident was given an order for oxygen, as needed, for shortness of breath and comfort, on 3/16/24. Staff indicated that (R1) will wobble when sitting in a chair and needs a reclining wheelchair to sit in. Resident’s responsible person stated(R1) started to have trouble breathing- she had "very labored breathing" and on the day she visited following the fall, a geriatric nurse from the hospital was there. The family member stated (R1) was "slumped over in her chair" and discussed possibly starting resident on hospice with the nurse, and the nurse agreed stating it may be better for (R1) if she does start hospice, explaining she and the Administrator previously discussed how (R1)"will fight going to the Emergency Room every time, and if she is on hospice, she doesn't have to go" as the facility can contact hospice personnel to come out. The responsible person stated she observed a staff member to be sitting in the same chair in (R1's) room when she visited a few days after the fall, and she did not observe any part of the chair to be broken. LPA did not observe any furniture to be broken or in disrepair on (3) separate occasions during the investigation. The staff (S7) who was present during the incident is no longer employed at the facility and was not able to be interviewed. Based on interviews conducted and documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099A-C-2... 9099A-C-2... Licensee has staff working without a criminal record clearance. The complaint alleges that 6 staff are not associated to the facility and the licensee will have staff working before receiving criminal background clearance. On 3/27/24, LPA and the Administrator discussed current staff associations, per the Department's fingerprint clearance system.. The Administrator showed LPA an email from a support staff from the Department who had recently been assisting with associating the (2) most recent staff. LPA was later provided with documentation of fingerprint clearance. On 4/17/24, LPA confirmed that both staff present, staff (S2 and S5) were associated on 3/18/24 and on 4/8/24. LPA was provided with additional printed clearances for multiple staff for (2) related facilities on 4/24/24. Based on documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility is not keeping medications locked away. Complaint alleges that medications are not locked away. LPA observed that medications were locked in the medication room during each of (3) inspections conducted and medications are prepared for the day only. LPA also did not observe any medication to be unsecured in the common areas or resident rooms during all inspections also. LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099A-C-3... 9099A-C-3.. Allegation: Facility is not keeping sharps locked away. The c omplaint alleges resident (R2) has access to razors and cut himself and the licensee refuses to lock razors away because resident does not have Dementia. Also alleges knives are not locked in the kitchen. Resident (R2) stated he uses both an electric razor and a manual razor and he is able to shave himself independently. Staff stated they provide standby assistance for (R2) who uses both types of razors- electric and manual with staff stating they are not aware that (R2) has ever cut himself. One staff stated a family member will allow R2 to use his electronic razor independently and that caused him to cut himself. Administrator stated R2's family member will often bring razors over for resident to use and place them in the resident's bathroom without staff's knowledge. Staff will now look in the bathroom following each visit. LPA observed (2) razors to be in a bathroom drawer on 4/17/24 and the Administrator immediately removed the razors and locked them up. Administrator stated that all staff will accompany residents into the bathroom. LPA observed there were no unlocked razors on 4/24/24. R2 does not have a diagnosis of Dementia. L PA observed where sharps to be locked in the kitchen on (3) occasions. LPA observe the drawer to be locked by a magnetic. LPA also observed markings on the drawer where the previous combination lock was previously used. The Administrator stated she prefers the combination lock as there is not a key or magnetic piece that could be misplaced. Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Residents are not being provided safe furniture. Complaint alleges resident (R1) fell and sustained injuries due to a chair that the licensee and staff knew the chair was broken. LPA toured (3) occasions and did not observe any broken chair or other furniture. All interviews conducted confirmed that no staff was aware that (R1's) chair was broken with a family member stating she visited resident on 3/14/24 and observed the same chair to be in the room as usual and it did not appear to be broken, stating that another care staff/woman was sitting in the chair folding laundry during her visit. Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. **cont on 9099A-C 4-.. 9099A-C-4.... Allegation: Facility is not providing medications as prescribed. The complaint alleges that medications are not being given as prescribed. LPA and staff(S2) reviewed medications for (1) resident (R3) on 4/17/24. Medications are being administered as ordered. R3's family member brought several bottles of vitamins that do not have an order yet from the doctor. The facility has reached out multiple times to the doctor to request orders before they can administer any. LPA Calzada and LPA Angela Hood reviewed medications for resident (R2) on 4/24/24 with staff,(S3). All medications are being administered as ordered and are being documented correctly on the Medication Administration Record (MAR). There was (1) PRN medication- Albuterol 108 (90 Base) that (R2) does not ask for that was not on hand currently. Facility will reach out to the doctor tomorrow and request the medication or obtain a discontinuance order. All staff interviewed indicated that medications are being given as ordered and a medication cannot be given until there is an order on hand. Based on interviews and medication review, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Copy of report provided to the Administrator Designee, Edith.